Late Abnormal Skin Changes Overlying Total Knee Arthroplasty: A Case Report.

Accurate knowledge of the location of tibiofemoral articular contact following total knee arthroplasty is important in order to understand polyethylene wear and the mechanisms of component failure. The present study was performed to determine the three-dimensional tibiofemoral articular contact patterns of a posterior cruciate ligament-retaining total knee replacement during in vivo weight-bearing flexion. Nine osteoarthritic patients who were managed with a single design of a posterior cruciate ligament-retaining total knee implant were investigated with the use of an innovative dual orthogonal fluoroscopic imaging system. The position of the components during in vivo weight-bearing flexion was measured from full extension to maximum flexion in 15 degrees intervals. Tibiofemoral articular contact was determined by the overlap of the tibiofemoral articular surfaces. The centroid of the surface intersection was used to report the point of contact location. The average tibiofemoral contact points on both the medial and lateral tibial component surfaces were reported as a function of flexion. The average maximum weight-bearing flexion angle was 113.3 degrees +/- 13.1 degrees (range, 96 degrees to 138 degrees ). In the anteroposterior direction, the contact location was relatively constant in the medial compartment and moved posteriorly by 5.6 mm in the lateral compartment as the knee flexed from full extension to 90 degrees of flexion. The range of the contact location in the mediolateral direction was 3.7 mm in the medial compartment and 4.8 mm in the lateral compartment. For both compartments, posterior translation of the contact point was significant from 90 degrees to maximum flexion, but the contact point at maximum flexion was not observed to reach the posterior edge of the polyethylene tibial insert articular surface. While the minimum anteroposterior translation of the contact point on the medial side might be interpreted as a medial pivot rotation during knee flexion, the contact point did move in the mediolateral direction with flexion. Beyond 90 degrees , both medial and lateral contact points were shown to move posteriorly but stopped before reaching the posterior edge of the polyethylene tibial insert articular surface. It seemed that the current component design did not allow the femoral condyle to roll off the polyethylene edge at high degrees of flexion because of the geometry at the posterior lip.

Q&A: Rating Patellofemoral Arthroplasty

BackgroundThe optimal type of anesthesia for reducing postoperative delirium remains undetermined. This study aimed to assess the relationship between type of anesthesia and postoperative delirium.MethodsThis retrospective national cohort study used data collected between 2016 and 2021 from the National Health Insurance Service of South Korea. Adult patients who underwent primary total hip or total knee arthroplasty under general or regional anesthesia were included. Patients with postoperative delirium were identified after arthroplasty according to the International Classification of Diseases 10th revision code for delirium (F05). The patients were divided into two groups: regional anesthesia (RA group) and general anesthesia (GA group). The primary endpoint was the incidence of postoperative delirium during hospitalization after total hip or knee arthroplasty.ResultsOur study sample consisted of 664,598 patients: 474,932 in the RA group and 189,666 in the GA group. After propensity score (PS) matching, 276,582 patients (138,291 in each group) were included in the final analysis. In the PS-matched cohort, the incidence of delirium following total knee or total hip arthroplasty was 2.8% (3,842/138,291) in the GA group and 2.3% (3,147/138,291) in the RA group. In logistic regression, the RA group was associated with 18% (odds ratio: 0.82, 95% confidence interval: 0.78, 0.86; P < 0.001) lower postoperative incidence than the GA group.ConclusionCompared to general anesthesia, regional anesthesia was associated with a decreased incidence of postoperative delirium in patients who underwent total hip or total knee arthroplasty. Our findings indicate that avoiding general anesthesia may prevent delirium after lower limb surgery.

Total knee replacement (TKR) and total hip replacement (THR) are 2 of the most common orthopedic surgical procedures in the United States. These procedures, with fairly low mortality rates, incur significant health care costs, with almost 40% of the costs associated with post acute care. We assessed the impact of general versus neuraxial anesthesia on discharge destination and 30-day readmissions in patients who underwent total knee and hip replacement in our health system. This was a retrospective cohort study of 24,684 patients undergoing total knee or hip replacement in 13 hospitals of a large health care network. Following propensity score matching, we studied the impact of type of anesthetic technique on discharge destination (primary outcome) and postoperative complications including readmissions in 8613 patients who underwent THR and 13,004 patients for TKR. Our results showed that in patients undergoing THR and TKR, neuraxial anesthesia is associated with higher odds of being discharged from hospital to home versus other facilities compared to general anesthesia (odds ratio [OR] = 1.63, 95% confidence interval [CI], 1.52-1.76; P < .01) and (OR = 1.58, 95% CI, 1.49-1.67; P < .01), respectively. Our results suggest an association between use of neuraxial anesthesia for total joint arthroplasty and a higher probability of discharge to home and a reduction in readmissions.

Scintigraphic Assessment of Patellar Viability in Total Knee Arthroplasty After Lateral Release

An integrative review of multimodal pain management on patient recovery after total hip and knee arthroplasty

Anterior knee pain is a major cause of complaint in total knee arthroplasty (TKA) without patellar resurfacing. The concept of improved patellar tracking and decreased retropatellar contact pressure for lateral retinacular release theoretically suggests that patients with lateral retinacular release in TKA would achieve a lower incidence of anterior knee pain when compared without lateral retinacular release. We sought to determine (1) whether those patients who received a routine lateral retinacular release in TKA would attain lower incidence of anterior knee pain as compared to patients who received TKA without lateral retinacular release and (2) whether lateral retinacular release would increase the lateral retinacular release-related complications. A total of 148 patients who underwent TKA with the use of the Gemini MK II mobile bearing were randomized to receive either routine lateral retinacular release (intervention group) or not (control group). Patients were assessed by the visual analogue scale for anterior knee pain, the Knee Society clinical scoring system of knee score and function score, and patellar score for clinical function. Patients' satisfaction and lateral retinacular release-related complications were also evaluated. The overall incidence of anterior knee pain in the intervention group at 18 months follow-up was 5.6%, while that of the control group was 20.6% (p = 0.009). No statistical difference was detected between the two groups in terms of lateral retinacular release-related complications (n.s.), patients' satisfaction (n.s.), knee score (n.s.), function score (n.s.), and patellar score (n.s.) at 18 months follow-up. The present study suggests that routine lateral retinacular release can reduce anterior knee pain and does not increase lateral retinacular release-related complications, in TKA with the use of the Gemini MK II mobile bearing without patellar resurfacing. Therapeutic, Level I.

Elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) are effective options for the management of osteoarthritis that has not responded to conservative therapy, and they are increasing in utilization worldwide. Therefore, we sought to investigate how older age influences the outcomes of THA and TKA through a review of the current literature. The Embase and MEDLINE databases were examined for relevant studies that assessed the role of older age in determining the outcomes of THA and TKA. All studies except for systematic reviews and case reports were considered for inclusion. Studies were excluded if they included data on procedures other than THA and TKA or if they focused on the effect of surgical techniques and rehabilitation programs rather than age. We excluded studies if they included data on total joint arthroplasty (TJA) performed for indications other than osteoarthritis unless osteoarthritis was the diagnosis for >90% of the patient cohort. Journal references were manually searched to identify any additional articles. Thirty-two articles were identified in this review. The most elderly groups in these studies were shown to experience higher mortality rates, more postoperative complications, and a longer stay in the hospital. Perioperative mortality was reported to be between 2.6% and 2.9% for nonagenarians and 1.09% and 1.54% for octogenarians. The increase in length of stay for the elderly following TJA was reported to be 0.6 to 3.1 days. Despite the increased rate of adverse events, there were gains in terms of pain relief and ability to perform activities of daily living, and overall the most elderly groups were satisfied with the THA or TKA. However, there was considerable inconsistency among studies with respect to the methodology for evaluating health-related quality of life and the level of functional ability postoperatively. Although TJA is considered an effective surgery for the elderly, clinicians should be aware that the elderly are at a higher risk of greater length of stay, complications, and mortality. However, the available literature contained poor data and heterogeneous patient cohorts, and reported on a wide variety of outcomes. Further research assessing the effect of older age on TJA is warranted.

Leveraging subject-specific musculoskeletal modeling to assess effect of anterior cruciate ligament retaining total knee arthroplasty during walking gait.

Whether the entire posterior cruciate ligament (PCL) should be retained during cruciate-retaining total knee arthroplasty (CR TKA) is controversial. The goal of this study was to compare the early clinical outcomes of partial versus intact PCL-retaining TKA. Ninety-two patients who had undergone unilateral CR TKA from March 2012 to June 2013 were enrolled in this study. Forty-six of these patients were randomly selected to undergo intact PCL-retaining TKA (intact group), whereas the remaining 46 patients underwent tibial osteotomy together with anterolateral bundle and bone island resection (partial group). All operations were performed by a senior orthopedic surgeon and the PCL was released to some extent in both groups. After TKA, active and passive flexion and extension exercises of the knee and lower limb strength exercises were maintained until at least 3 months after surgery. Before surgery and 6, 12, and 24 months after surgery, range of motion, Knee Society Clinical Rating System scores (including clinical and functional scores of the knee) and maximum anteroposterior (AP) displacement of the knee at 30° and 90° of knee flexion were evaluated in both groups. Fourteen patients were rejected from the final analysis because of loss to follow-up or development of complications. Thus, 40 patients from the partial group and 38 from the intact group were followed up for 24-41 months (mean 32.8 months). Knee functional scores were significantly higher in the intact than in the partial group (88.1 vs. 84.8 points) 24 months after surgery There were no significant differences in range of motion or knee clinical scores between the two groups at any time point. However, 12 and 24 months after surgery, the mean maximum AP displacement of the knee in 90° knee flexion was significantly greater in the partial than in the intact group (12 months: 6.3 vs. 5.7 mm; 24 months: 7.0 vs. 6.2 mm). Double-bundle PCL plays an important role in maintaining knee stability; the entire PCL should therefore be retained during CR TKA.

7We previously reported the minimum eight-year follow-up results of cruciate-retaining total knee arthroplasty in a consecutive series of seventy-two knees in patients with rheumatoid arthritis. In the present study, we evaluated the longer-term outcomes after twenty to twenty-five years of follow-up. Since the publication of our original study, ten knees have been revised: three because of periprosthetic fracture, three because of infection, two because of patellofemoral failure, and two because of posterior instability. The rate of implant survival at twenty years after surgery was 69% (95% confidence interval [CI], 56% to 79%) with revision for any reason as the end point, 81% (95% CI, 69% to 89%) with femoral or tibial component revision for any reason as the end point, and 93% (95% CI, 83% to 97%) with posterior instability as the end point. These long-term results demonstrate that posterior cruciate ligament insufficiency with instability was rarely the cause of failure following cruciate-retaining total knee arthroplasty in patients with rheumatoid arthritis.

Pharmacologic thromboprophylaxis for postoperative venous thromboembolism (VTE) after total knee arthroplasty (TKA) and total hip arthroplasty (THA) in people with hemophilia (PWH) is highly controversial. In PWH the prevalence of symptomatic VTE after TKA and THA is between 0 to 5%, while the prevalence of asymptomatic VTE is between 7.5% and 10%. In PWH many clinicians have not used pharmacologic thromboprophylaxis. Others have used low molecular weight heparin (LMWH) and reduced doses of DOAC [direct oral anticoagulants (thrombin inhibitors and Factor Xa inhibitors)]. It appears that pharmacologic thromboprophylaxis should only be carried out in PWH undergoing TKA and THA who have VTE risk factors [e.g., old age, prior VTE, varicose veins, general anesthesia, cancer, Factor V (Leiden) mutation, and obesity]. After TKA and THA in PWH, early mobilization is essential. Some authors have advocated additional mechanical thromboprophylaxis (pneumatic compression devices). In conclusion, for all PWH experiencing TKA and THA mechanical prophylaxis is sensible. Some form of pharmacologic prophylaxis should be strongly considered for PWH with clear risk factors. The main area of doubt is in PWH without risk factors. More prospective multicenter studies are required. Difficulties will be getting agreement on universal regimes to be followed; and the relatively small numbers of PWH experiencing TKA and THA.

What's New in Hip Replacement.

Objective To observe the effect of two methods of preemptive analgesia for postoperative analgesia after total knee replacement. Methods Forty patients undergoing selective total knee replacement under general anesthesia were randomly divided into group A and group B, 20 cases in each group. The patients in group A received local infiltration anesthesia by the operation doctor; group B received femoral nerve block by anesthesiologists under ultrasound guidance before induction. Patient-controlled intravenous analgesia was used in all patients after the operation. Remifentanil dosage, postoperative visual analogue scale (VAS) at rest and during exercise, patients' satisfaction and postoperative functional rehabilitation of knee joint HSS score and knee range of motion were observed. Results The dosage of remifentanil in group B was significantly less than that in group A. There was no statistic difference in VAS at 6 and 12 h after the operation, but VAS in group B was significantly lower than that in group A at 24, 48 h after the operation. There were no significant differences between the groups in knee function HSS scores after 3 months and knee ROM after 14 days (P>0.05) . Conclusion The two kinds of preemptive analgesia can be used for total knee replacement. Ultrasound guided femoral nerve block can lessen analgesics dosage, reduce the pain, promote the early functional exercise of knee joint, which is more suitable for total knee replacement. Key words: Preemptive analgesia; Ultrasound guidance; Femoral nerve; Nerve block; Arthroplasty, replacement, knee

A Novel Extended-Release Analgesic Without Periarticular Injection Provides Inferior Immediate Postsurgical Pain Relief in Total Hip and Knee Arthroplasty Patients